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Original Question

The following documentation is from the health record of a 52-year-old patient. Discharge Summary Admission Date: 11/14/XX Discharge Date: 11/17/XX Discharge Diagnosis: 1. Diabetic ketoacidosis, type 1 diabetes 2. Dehydration 3. Congestive heart failure 4. Aortic valve stenosis 5. Urinary tract infection due to Pseudomonas aeruginosa 6. Hyperkalemia 7. Peripheral vascular disease 8. Hypertension 9. Hyperlipidemia 10. Chronic renal insufficiency 11. Old myocardial infarction 12. Tobacco dependence 13. Coronary atherosclerosis with native coronaries Admitting Diagnosis: 1. Diabetic ketoacidosis 2. Diabetes mellitus type 1 3. Dehydration 4. Congestive heart failure 5. Hyperkalemia 6. Hyperlipidemia 7. Hypertension 8. Tobacco dependence 9. Severe peripheral vascular disease 10. Atherosclerotic coronary artery disease 11. Urinary tract infection 12. Renal insufficiency 13. History of CVA Present Illness: A 52-year-old white female with known diabetes mellitus type 1, CVAs, cellulitis, hypertension, chronic renal insufficiency, hyperlipidemia, poorly compliant diabetic. Most recently in hospital from September 3 to September 8 with cellulitis, congestive heart failure, poorly controlled diabetes with diabetic ketoacidosis. Discharged home. She was supposed to be following up with her primary care physician doing b.i.d. Accu-Cheks. She was nauseated for the previous two weeks. As soon as she got nauseated, she quit checking her blood sugar level. She cancelled her physician’s appointment because she was “too sick to go.” She had decreased appetite and was feeling poorly overall. She came to the emergency department with a blood sugar of 737. She had ketones 200 to 250. Her blood urea nitrogen was 75, creatinine 1.8. Her potassium is 6.1, chloride 5, bicarb at 13. Patient is a poor historian, although she is awake and alert at the time of evaluation, on an insulin drip. Overnight her nausea had resolved. The nausea probably occurred because she was in the beginning stages of diabetic ketoacidosis. Hospital Course: The patient was put on insulin drip. Blood sugars got down. She was put on q.i.d. Accu-Cheks. Once her blood sugar level came down to the 100s, potassium was lowered. I had a very lengthy discussion with patient about the need for keeping physician’s visits and checking blood sugars. The patient was placed on Cipro. Her electrocardiogram showed a prolonged Q T. The patient went to ultrasound and had sludge and possible small stones in her gallbladder, and it was felt that she was able to be discharged home improved. Discharge Medications/Instructions: Insulin 70/30, 20 units in the a.m., 20 in the p.m., Rezulin 400 mg q. a.m., Tenormin 50 q.d., Plavix 75 q.d., Monoket 10 mg b.i.d., Lasix 20 mg b.i.d., aspirin 325 q. a.m., Zocor 20 once a day, Prozac 20 q. a.m., Vasotec 5 mg q. a.m., Propulsid 10 mg at Ac and HS, Bactrim DS one tablet every 12 hours. She is to see her primary care physician in one week. She is to call if she has any difficulties. Disposition: Discharged home History and Physical Past Medical History: The patient has history of renal insufficiency with a blood urea nitrogen of 30 to 40 with a creatinine of 1.2 to 1.4. She has had a CVA, severe peripheral arterial disease. Echocardiogram done shows aortic stenosis, mitral leaflet thickening, normal left ventricular size, normal diabetes. Smokes three to four packs of cigarettes a day. She has hypertension. She has hyperlipidemia. She is dehydrated. She has a history of atherosclerotic coronary artery disease. Medications: At the time of admission included Rezulin 40 mg q.d., Prozac 20 q.d., Propulsid 10 a.c. and h.s., Vasotec 2.5 two every morning, Atenolol 50 q. a.m., Plavix 75 q. a.m., Lasix 20 milligrams b.i.d., Novolin 70/30 20 units every a.m., aspirin 325 q. a day, vitamin E, iron, Zocor 20 mg at dinner. The patient has no known drug allergies. Social History: She is married but her husband lives out of state and works there. She has one daughter. She does not drink and has smoked about three to four packs of cigarettes a day since a teenager. Physical Exam: At the present time, the patient is afebrile, vital signs are stable. She is awake and alert, oriented times 3. HEENT: Pupils equal, round, reactive to light and accommodation, extraocular muscles intact, oropharynx benign. Neck: Supple without adenopathy or jugular venous distention Lungs: Clear to auscultation Heart: Reveals a regular rate and rhythm without murmurs, gallops, or rubs Abdomen: Soft, nontender, positive bowel sounds, no masses noted GU: Deferred Extremities: No edema. She has a baseline edema currently. Pulses are absent, pedal pulses. Laboratory: At the time of admission, her glucose was 737, blood urea nitrogen 75, creatinine 1.8, acetone greater than 200, less than 250, sodium 136, potassium 6.1, chloride 95, bicarb of 13. Her hemoglobin was 13.9 and hematocrit of 44.1, white blood cell count of 9.2 with a left shift showing 80.2 percent neutrophils, 16.2 percent lymphocytes. Platelets were 241,000. Urinalysis shows positive nitrites, greater than 1,000 glucose, 30 protein, 15 ketones, trace hemoglobin. She had 13 white blood count per high power field. Rare red per high power field, 21 bacteria. Gram stain on her u/a showed no organisms seen. Impression(s): 1. Diabetic ketoacidosis 2. Diabetes mellitus type 1 3. Dehydration 4. Congestive heart failure 5. Hyperkalemia 6. Hyperlipidemia 7. Hypertension 8. Tobacco dependence 9. Severe peripheral vascular disease, arterial in nature 10. Atherosclerotic coronary artery disease 11. Urinary tract infection 12. Renal insufficiency Plan: Admit, hydrate. She has been on insulin drip, we will d/c this now and change to q. 4 Accu-cheks and continue sliding scale. Hopefully on 16th be able to reinstitute her routine meds. Her potassium has now come down to the mid 4’s secondary to her hydration and her sugar being driven intracellular with the insulin drip. I have impressed upon the patient the need for checking blood sugars and keeping M.D. appointment versus death in the future. The patient is on Cipro for her urinary tract infection. Further workup as indicated during hospital stay. Code Assignment Including POA Indicators

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